Claims Specialist

Role Overview

The Claims Specialist role is a full-time remote position focused on absence case handling and claims review. The work centers on evaluating medical evidence, applying disability, FMLA, and paid family leave rules, and determining the correct benefit outcome while keeping payments and adjustments accurate and timely.

Key Responsibilities

• Manage absence cases and adjudicate claims using medical records and the relevant disability, FMLA, and paid family leave guidelines.
• Evaluate claim details, eligibility, and claim type, including intermittent and continuous cases.
• Review medical evidence such as attending physician statements, diagnostic reports, office notes, and operative records to assess disability status.
• Approve or deny FMLA claims in line with insurer standards and employer policy.
• Assess claims, authorize benefits, and calculate payouts according to U.S. paid family leave regulations.
• Identify claims that are incomplete, obtain missing documents, and coordinate outreach with employees, physicians, or employers as needed.
• Communicate expectations and claim status clearly to claimants and clients through phone or written communication.
• Monitor client deliverables, handle overall workload, and support second-level escalations.
• Settle benefits, issue payments, and make adjustments for workers’ compensation, state short-term disability, and other disability offsets.
• Escalate cases to the team lead or clinical case management when necessary.
• Own daily workload management, first-level escalations, and quality/timeliness reviews, including peer review support where applicable.
• Contribute ideas for service improvement and stronger service-level management.
• Take on additional duties and special projects as assigned.

Required Experience and Knowledge

• At least 1 year of experience in disability, FMLA, PFL, or insurance claims handling.
• Hands-on experience with FINEOS.
• Working knowledge of medical terminology and common claim documents such as APS, diagnostic tests, and imaging reports.
• Strong understanding of disability insurance claims, benefits administration, offsets, deductions, disability duration, and medical management practices.
• Excellent verbal and written communication skills, including the ability to present information clearly.
• Strong analytical ability, sound judgment, problem-solving capability, and people management skills.
• Comfortable using computers and business software, with solid keyboarding ability and proficiency in MS Office tools such as Excel, Word, and PowerPoint.
• Ability to adapt quickly in a fast-moving environment and a willingness to embrace change.
• Commitment to continuous learning and ongoing improvement.
• Ability to recognize escalated cases and partner with the team lead to create an action plan.

Additional Information

This position is remote and requires full-time availability. The role specifically calls for experience with long-term disability, short-term disability, FMLA, and paid family leave interpretation.